A nurse is contributing to the care plan of an older adult client who has pneumonia. Which of the following interventions should the nurse include in the plan?

Encourage fluid intake of 2.5 L per day.

Assist the client to cough and deep breathe every 4 hr.

Encourage independence in completing ADLs.

Use an N-95 respirator when providing client care.

Answer and Explanation

The Correct Answer is A

A. Encourage fluid intake of 2.5 L per day.

This is an appropriate intervention for a client with pneumonia. Increasing fluid intake helps to thin respiratory secretions, making them easier to cough up and clear from the airways. Adequate hydration also supports overall health and immune function. However, the nurse should consider the client's individual fluid tolerance and any comorbid conditions such as heart failure that may necessitate fluid restriction.

B. Assist the client to cough and deep breathe every 4 hr.

This intervention is also appropriate for a client with pneumonia. Coughing and deep breathing exercises help to mobilize and clear respiratory secretions, preventing complications such as atelectasis and pneumonia. However, the frequency of coughing and deep breathing may need to be tailored to the client's tolerance and respiratory status.

C. Encourage independence in completing ADLs.

While promoting independence in activities of daily living (ADLs) is generally beneficial for older adult clients, in the context of pneumonia, the priority is to ensure adequate rest and conserve energy for recovery. Depending on the severity of the illness, the client may experience fatigue and dyspnea, making it challenging to perform ADLs independently. The nurse should assess the client's functional status and provide assistance as needed while promoting independence to the extent possible.

D. Use an N-95 respirator when providing client care.

This intervention is not directly relevant to the care plan for a client with pneumonia. N-95 respirators are primarily used for respiratory protection against airborne infectious agents such as tuberculosis or certain viral infections like COVID-19. While standard precautions should be followed when caring for a client with pneumonia to prevent the spread of infection, including hand hygiene and appropriate use of personal protective equipment (PPE), an N-95 respirator is not typically indicated unless the client has a specific respiratory pathogen requiring airborne precautions.

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Correct Answer is D

Explanation

A. Asking the provider to repeat another radiograph of the chest.

This option is not the most appropriate action in this scenario. While a chest radiograph may be useful in certain situations to assess for complications such as pneumothorax or pneumonia, it is not typically the first intervention for an asthma exacerbation with increased wheezing and decreased oxygen saturation. In this acute situation, the priority is to provide immediate treatment to alleviate the client's symptoms and improve oxygenation.

B. Increasing oxygen to maintain an oxygen saturation of 95% or greater in the client.

While maintaining adequate oxygenation is important, especially in a client with asthma exacerbation, it is not the first-line intervention in this scenario. Oxygen supplementation may be necessary, but the priority is to address the underlying bronchospasm causing the decreased oxygen saturation. Therefore, this option may be considered after initiating appropriate bronchodilator therapy.

C. Requesting the pharmacy to dispense 10 mL of dextromethorphan PO.

This option is not appropriate for managing an asthma exacerbation. Dextromethorphan is a cough suppressant and does not address the underlying bronchospasm characteristic of asthma exacerbations. In fact, suppressing cough may hinder the clearance of mucus and exacerbate respiratory distress. Therefore, this intervention is not indicated and may delay appropriate treatment.

D. Instructing respiratory therapy to administer a PRN albuterol aerosol.

This is the correct action in this scenario. Albuterol is a short-acting bronchodilator commonly used to relieve bronchospasm and improve airflow in clients experiencing asthma exacerbations. Administering albuterol via aerosolized inhalation helps to quickly deliver the medication directly to the airways, providing rapid relief of symptoms such as wheezing and improving oxygenation. Therefore, instructing respiratory therapy to administer a PRN albuterol aerosol is the most appropriate intervention to address the client's acute symptoms.

A. Offer small frequent meals B. Encourage extra liquids with meals C. Assist the patient to exercise before meals D. Supply information about nutrition

Correct Answer is A

Explanation

A. Offer small frequent meals

Offering small, frequent meals is beneficial for patients with COPD because it helps overcome the challenges associated with dyspnea and fatigue. Large meals can cause discomfort and increase the effort required for breathing, which can exacerbate respiratory symptoms. By providing smaller, more manageable portions of food throughout the day, patients with COPD can maintain their energy levels and meet their nutritional needs without experiencing excessive respiratory distress.

B. Encourage extra liquids with meals

Encouraging extra liquids with meals can help prevent dehydration and thin respiratory secretions, making it easier for patients with COPD to manage their respiratory symptoms. However, excessive fluid intake can also lead to feelings of fullness and discomfort, especially in patients with compromised lung function. Therefore, while it's important to encourage adequate hydration, particularly during meals, it's also essential to balance fluid intake to avoid exacerbating respiratory symptoms.

C. Assist the patient to exercise before meals

While regular exercise is beneficial for overall health and can help improve respiratory function in patients with COPD, exercising immediately before meals may not be practical or advisable for all patients. Patients with COPD may experience fatigue and dyspnea during physical activity, which can affect their ability to eat and digest food effectively. Additionally, exercising before meals may increase energy expenditure and exacerbate respiratory symptoms, making it more challenging for patients to consume an adequate amount of nutrients. Instead, patients with COPD may benefit from engaging in light physical activity or respiratory exercises at a different time of day to improve their respiratory function and overall well-being.

D. Supply information about nutrition

Providing information about nutrition is essential for patients with COPD to help them make healthy dietary choices and manage their condition effectively. However, simply supplying information may not be sufficient to enhance the nutritional status of patients with COPD. It's important to offer practical guidance and support, such as meal planning tips, dietary modifications, and strategies for overcoming barriers to healthy eating. Additionally, individualized dietary counseling from a registered dietitian can be beneficial for patients with COPD to address specific nutritional needs and preferences.

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A nurse is contributing to the care plan of an older adult client who has pneumonia. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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